Patient-Doctor Discussion #1

A patient talks about Dr./Pt communication.

What is The Clinical Excellence Podcast?

The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.

[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, I'm joined by one of my patients.

[00:00:09] Patient: I think one element that's constantly discounted, I think you as a doctor are sensitive to this and a few other people are, but most aren't is the different nature of time for the doctor and the patient.

To the doctor, we'll get the result tomorrow seems pretty immediate. To the patient that might mean I'm going to sit up for the next 24 hours wondering if I'm going to die.

[00:00:31] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast sponsored by the Bucksbaum Institute. During this podcast, we discuss, dissect, and promote clinical excellence.

We review research pertinent to clinical excellence. We invite experts to discuss topics that often challenge the physician-patient relationship, and we host conversations between patients and doctors. I'm Adam Cifu, and today I'm joined by one of my patients. She and I decided that we would not use her name today so that she could speak freely, which I trust, she will.

She's a prominent academic with expertise in communication, and she's here to talk about patient-doctor communication from the patient side of things. Thank you very much for joining me.

[00:01:10] Patient: It's a pleasure.

[00:01:11] Dr. Cifu: So you're someone who professionally thinks a lot about how people communicate and actually how to teach people to communicate, you know, more effectively or better.

You're also someone who's certainly seen the medical profession from the patient side and has not been shy about telling me your thoughts. So maybe sort of limiting ourselves to just the doctor-patient communication, which is what we're here for, I'll ask you, kind of what have you seen well in your interactions with medicine?

[00:01:40] Patient: Well, I'd say what for me really distinguishes the best doctors who I trust from the ones I have a great deal of disdain for, is not actually what comes out of their mouth, but their ability to listen and process what I have to say. To understand what the problem is, how I see it, what matters to me about it, and then in turn to respond to me as an individual, not someone who's reading something you could get off mayoclinic.com to me about whatever the thing is, but something tailored to me that they know I can use in the context of my life. Um, so someone doesn't tell me, "Go to the gym eight hours a week," because they know it's not happening, I graduated from the college here in the eighties and that's who I am.

So someone who will instead give me something that's very personalized, that shows that they hear me. So I think that really, the best listeners make the best communicators.

[00:02:39] Dr. Cifu: What do you think...? I'm already getting to go off my script. What do you think...? That seems pretty obvious, right? And it is something that we certainly teach medical students, right? We say, "Listen to the patient, they'll tell you what's wrong with them." You know, that's like some classic thing that probably—

[00:02:56] Patient: Ah, but you see, what you say is tell them what's wrong. That isn't always the only piece of information to extract, and that's part of the problem. They are looking for little pieces of information. They're not actually listening to the whole of the situation. And that leads them to see the patient as a disease and a constellation of symptoms, not a human being with a disease or a constellation of symptoms. So I think that's part of the problem.

[00:03:24] Dr. Cifu: So before you cut me off, I was going to say, what do you think gets in the way of people doing that? Because, you know, also when we teach students, you know, look, this is a medical history, right? It involves... We think about the biopsychosocial model of medicine and that you should learn who is this person, where are they coming from? You know, what are their concerns? What are they looking for in their life?

But I mean, I know that doesn't happen, right? And you're clearly expressing that doesn't happen. Do you have a sense why that is?

[00:03:57] Patient: Um, maybe it's because it's something that really can't happen in one meeting. It's not something that you can sort of "do". It's what we in the law call soft information. And even the person who knows the information, the patient might not have the words to communicate it to the doctor.

It may be something that the doctor learns from watching the way the patient reacts over time, over years. So I don't think it's necessarily something that's fully the fault of the doctor, nor is it the fault of the patient. I think it's more the system that rushes doctors, that rushes patients, um, that focuses so much on symptom and disease rather than a human being.

So I'll give you an example. I call a clinic here, a general clinic, gynecologist, let's say. And they say, "What's wrong with you?" "So, I don't know. I have pain in that general, in the lady parts." So they say, "Well, what's the diagnosis?" So, why? They say, "Well, the doctor sees this disease on Monday and that disease on Thursday, which is it?" I said, "Well, that's the question." "I'm sorry I can't put you on the schedule."

Well, is that person hearing? There's something profoundly messed up about that approach and it starts well before the doctor and the patient. You know, I don't think it's something you can expect a young person to learn to do in one setting. I think maybe that's part of the problem.

[00:05:27] Dr. Cifu: Yeah, I love that point because it is something that we often have to talk to the residents over and over again. And this is in the, you know, sort of the general medicine, primary care clinic that like you don't need to get everything done this visit, right? This is a relationship.

This person's... If they're not dying in front of you, right? This can take three years to sort of cover everything and establish the relationship. And it's interesting, I think that just doesn't sort of fit into a undergraduate medical education, kind of medical school communication or clinical skills type of course. That's not the model of like making a diagnosis.

Okay. So this is probably a predictable question given what we've talked about already, and maybe you'll just say, "I already answered that question," or maybe you want to expand on it a little bit. But, you know, what are the specific things that you've seen done poorly, that you would say, "God, you know, you got to change that"?

[00:06:23] Patient: Well, um, to be honest, when I've seen it, I have mostly spoken up in a contemporaneous sort of way. Um, so I had a mastectomy and they gave me both pre-op and post-op instructions. And as someone whose academic specialty involves the precise use of language, let us say, neither set of instructions was clear.

I had absolutely no idea what these instructions were talking about, and I'm a highly educated person and I couldn't believe that the night before a major surgery, which is stressful enough, you open this package of wipes and the instructions from the clinic and the instructions on the wipes are completely contradictory.

[00:07:05] Dr. Cifu: Right, right.

[00:07:06] Patient: And they can't both be done. And things like this just add stress, or aftercare instructions for dealing with Pratt drains and things like this. I think that medicine needs to be a little more open, that there may be other people than doctors who can write with greater precision, technical writers, bring in some extra expertise.

So I find that instruction-giving, which is done more by nurses actually than by physicians, could use a lot of improvement around here.

[00:07:37] Dr. Cifu: It's interesting to hear that because there are whole specialties of that, right? I mean, there are obvious people to bring in to work on that stuff. And some of the people who've done interesting work here have worked with, sort of, you know, graphic art to say like, "How can we teach this better at basically any reading level?" Right? And it's surprising that we haven't gone further with that because it would also be a really exciting sort of area to collaborate with outside fields and outside specialists.

[00:08:08] Patient: Look, even lawyers whose livelihood, if you're a contract lawyer, depends on the precise use of language, are only at the very early stages of integrating graphics and different techniques into the drafting of contracts, but there's a lot of really interesting work being done on that at the University of Helsinki. So you might want to have a look at that.

[00:08:29] Dr. Cifu: Great. So let's go to another world and imagine, some medical school called you up and said, "You know, we heard this podcast," because boy, everybody listens to The Clinical Excellence Podcast, and said, "We'd like you to design a curriculum for whatever year student you want, you know, first year, second years, people who've already been in the clinic, on how to communicate effectively with your patient. Where do you think you would start with that? Sort of where would you get at these students? How would you teach them that?

[00:09:01] Patient: Um, well one of the things I found in trying to teach communication is a little bit ironic, but goes back to a children's book called The Berenstain Bears.

[00:09:12] Dr. Cifu: Love The Berenstain Bears.

[00:09:13] Patient: I love it. So Daddy Bear says, "We're going to go camping and live off the land." Nothing works, and he turns to the kids and says, "This is what you should not do. Let it be a lesson to you." So I find that teaching my students how to present academic papers, showing them the good, forget about it.

I show them the bad. I put them in the position first of being the critic rather than the criticized, and I turn them into vicious critics. They can look at any presentation and take it apart six ways to Sunday. Then when they go to do it, they think it's easy because it's so easy to say what's wrong, they discover, uh, not so quick and they know how to self-criticize.

And then they say to themselves, "Oh my God, I have no idea what I'm doing." And at that point, their minds are open. It's not like, who are these idiots telling me how to communicate? This is just a box I have to check to get through the process. So that's how I sort of condition them to get them ready to hear what they need to hear.

And we do a lot of work, um, where they have to talk and see if people are understanding them. And not just experts, not just the big boss professor, but go around the room, take the model doctor-patient conversation. Ask a resident to say how they would do the oral note on the visit. Then ask someone else and someone else.

And as you get more, you see very quickly how different people watching the same thing, hear completely different things. And that again opens the students' minds to just how hard this is. Because I think people think communication is easy. People say, "You're teaching students who are going to spend their lives communicating. What do you mean you need a course in communication?" I can't even call it a course in communication. I call it something completely different, but it is a course in communication.

[00:11:08] Dr. Cifu: I love the way you talk about, you know, sort of teaching the critique because where I see that done often in the curriculum is where people critique classmates, right?

So classmate interviews a patient, four students watch that and have to give feedback, but it's terrible because everybody's trying to be too gentle, right? Even the faculty member who's there at the time doesn't want to come off as the jerk being like, "I'm the one person who's going to criticize the student."

Where I see it work best is exactly as you say, is when you're watching a video of yourself, right? You know what doesn't work, you see it, you're appalled by it. And then often having somebody there, maybe just going over the video who wasn't there with the patient to say like, "Okay. You know, tell me what you did wrong," and then to build on that, but it's a great idea and so interesting to really start with, okay, we're going to watch someone else do this and, you know, maybe they're good, maybe they're bad, but there's always something they can improve on and let the students start working there.

[00:12:10] Patient: Well, the other way to diffuse that reluctance to criticize peers is to task the person doing the interview and say, "I want you to do some things deliberately well, and some things you think shouldn't be done." And that way it feels like the things that shouldn't be done are just there to be identified, and of course, the person did it deliberately. And that's a way to break down the barrier of shame in the classroom, if you have to do it in the classroom.

[00:12:39] Dr. Cifu: That's great. I had a wonderful experience as a medical student, and I'll tell a story because it's my podcast, I can tell a story. It was when I was a medical student and was interviewing a patient on the psychiatry service, which was videoed, and then we watched it and I thought I was falling apart. I couldn't figure anything out with this poor man I was interviewing, and as my classmates watched it, they were like, "Oh my God, you did such an amazing job pulling him out." And it's because I didn't realize at all that this person was psychotic. He was talking about his hallucinations, and I was so confused that I kept on asking questions and my wonderful classmates, I don't know if they didn't realize that I couldn't figure out what was going on, or they were just being kind, but it was a learning experience.

Um, so you fortunately have a lot of time in front of you as a patient. I know from working with you over the years that you are not shy about telling people how you feel, and you generally, I think you don't think so, but you generally do it in a good, productive way.

How do you feel, like you work well with the doctors, you do work well at to sort of give feedback, as times go, and are there suggestions to sort of both the doctors, I guess, who listen to this and the patients who listen to this about like, how can you as a patient or you as a doctor looking at your patients sort of improve in this realm?

[00:14:03] Patient: Well, I think as a patient I could be more concise. Um, that's something I could control and certainly do better.

[00:14:12] Dr. Cifu: And that's in the feedback you give, you mean?

[00:14:14] Patient: No, no, I mean in how I present information to a doctor. Sometimes I'll get nervous. I'll present some of the information, then it'll dawn on me an hour later something else.

It's probably better to wait, you know, four or five hours until things have unfolded and then explain it all at once, that would be more courteous and respectful of someone's time, but I think one element that's constantly discounted, I think you as a doctor are sensitive to this and a few other people are, but most aren't is the different nature of time for the doctor and the patient.

[00:14:50] Dr. Cifu: Hm.

[00:14:51] Patient: To the doctor, we'll get the result tomorrow seems pretty immediate. To the patient that might mean I'm going to sit up for the next 24 hours wondering if I'm going to die. And time goes a lot slower when you think you are going to die. And so things like, um, giving someone a heads up even a few hours earlier about a test result, even if it's just a text, "All clear, talk to you later," can make all of the difference.

And it also signals that the person understands that this isn't easy. Um, and it's not routine. It may be routine for the doctor, but it is nowise routine for the patient. And I guess I'm very critical of the medical system in general, but I am very happy with the care that I receive here. In fact, it would be probably my primary reason for staying at the University of Chicago, which might surprise you, but I just feel like I could not have a team that lets me think less about my own health, which in my case is a good thing, than the team I have here. Because you communicate, because you listen, because you talk to one another, and because most of you are what I call legacy doctors, and that is doctors who treat faculty as if they're colleagues.

[00:16:17] Dr. Cifu: Yeah. That's when I reflect... there are a lot of things that you said that I wanted to say something about, but it's interesting when I reflect on my kind of growth as a physician, the thing that I've realized, you know, over the years is the ability to treat all of my patients as peers. And that's hard because, you know, everybody's so different. People are different ages. You know, you go through so much time where like everybody's senior to you, but after you kind of breakthrough and get to that point where you feel comfortable with that, that like—

And part of it's, you know, getting old and having spent a lot of time on the patient side, myself now, but everything works better. You know, you can feel it in the room, the way the patient's interacting with you and you know, empathy is so much easier when you're talking to a friend, even if it's someone who you wouldn't want to talk to once you leave their room, right?

Your point about, you know, people waiting for information, that's one of those things that what I was taught was so wrong because we learned so much, "Oh, you know, never give bad news on a Friday." You know, worse than getting bad news on a Friday, is waiting through the weekend for news that you think is going to be horrible.

So, you know, put aside an hour to give the bad news on a Friday and then put aside time on Saturday and Sunday that you can follow up with the person, you know, if they need to sort of debrief at other times over the weekend.

[00:17:43] Patient: Well, that's what makes you an exceptional doctor. I mean, with some doctors in the system in general, it always shocks me, as a teacher here, I give my students my home phone number and tell them they can call me 24/7 for anything, to discuss anything they want, as long as it's not the subject matter of our class. If they want to call, I say, "If you want to call at four in the morning and discuss bird watching, I'll do it," because I never know when someone is going to have suicidal thoughts, and just having someone on the other end of the phone is going to make all the difference.

And it's always ironic to me that here I am an educator and my students can reach me anytime. My father was a corporate lawyer who worked for things like General Motors and big oil titans, his clients could reach him 24 hours a day. Yet I could get a voicemail saying, "You have a tumor in your brain," and not be able to reach anybody for 24 hours.

A world like that, wholly apart from the medical system, is just a world that doesn't have its value straight, all around. And I think the medical system needs to catch up a little bit with the fact that the world is what it is and not everybody can drop everything in their life to attend to their medical care. And that's something that I think is important.

[00:19:09] Dr. Cifu: I want to thank you so much for coming and sitting with me and talking about this stuff. This was really interesting. I think I learned some stuff, and hopefully our listeners learned something as well. So thanks for joining us for this episode of The Clinical Excellence Podcast.

We're sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas on the Bucksbaum Institute Twitter page. The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.